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07/08/20
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Delaware
Florida
Georgia
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Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Ohio
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South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Primary #
Secondary #
Fax #
Attention
How will you pay for the order:
ACH
Check
Credit Card
Cash
Other
Please make checks payable to: Korner Wholesale
Mail your check to: 10807 Rt. 322 Shippenville, PA 16254
Please call (814)-297-2104 to make a payment over the phone.
** There will be a 5% credit card fee **
Bank Name
Bank Address
Account #
Routing #
EIN #
SS #
Business Operation:
Wholesale
Retail
Chain Store
Business Type *
Proprietorship
Partnership
Corporation
LLC
Government
Trust
Non-Profit
State Organized in *
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Are you exempt from paying or collecting sales tax (if yes) please provide your tax-exempt certificate:
Please upload companies valid tobacco license:
Have you been denied a credit application before?
Yes
No
Please provide business references:
Person Name
Phone #
Company Name
Company Address
City
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Person Name
Phone #
Company Name
Company Address
City
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
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Ohio
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Washington
West Virginia
Wisconsin
Wyoming
Zip
Person Name
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Company Name
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Select State
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Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
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Iowa
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Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
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Texas
Utah
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